Healthcare Provider Details

I. General information

NPI: 1902169568
Provider Name (Legal Business Name): SHANNON DEMAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2012
Last Update Date: 10/26/2026
Certification Date: 10/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50M AUDUBON RD
WAKEFIELD MA
01880-1203
US

IV. Provider business mailing address

800 W CUMMINGS PARK STE 4050
WOBURN MA
01801-7224
US

V. Phone/Fax

Practice location:
  • Phone: 781-787-3003
  • Fax: 781-281-2406
Mailing address:
  • Phone: 781-787-3003
  • Fax: 781-281-2406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD60960857
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number1024424
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: